His smile evaporated after the next thing I said.
But I'm getting ahead of myself. Let's go back to a more appropriate portion of the story: the beginning.
Annabel (still not her real name™) was brought to me just before 1 AM on a Saturday morning, having been ejected from the car she had been driving. The first lesson Annabel apparently never learned was to wear your damned seatbelt, because if she had been wearing it she would not have been ejected. The second lesson she very clearly never learned (which both MomBastard and Mrs. Bastard drilled and continue to drill into my head) was to wear a coat in winter, because Annabel was not wearing one when she was found in a pile of ice and snow.
"Hey Doc, this here is Annabel. She drove her car through a farm."
A farm? Just when I'd thought I'd heard it all. My look of utter bewilderment apparently prompted the medic to continue.
"Yeah, she crashed through a whole bunch of stuff including a fence. We found her outside the car on the ground in the ice. She's real cold and she's been unresponsive the whole time. Blood pressure has been fine though."
On my initial evaluation she was ice cold and indeed unresponsive. She was moving all of her extremities (good) in an uncontrolled fashion (bad), so while I considered the possibility of a brain injury, my concern for a serious neck injury was rather low. But my concern for an Everything Else injury remained high. Because she was both unresponsive and uncooperative (a rather difficult combination), we intubated and sedated her to protect her airway and allow us to complete our examination. As the anaesthesiologist was inserting the breathing tube, I performed her abdominal ultrasound.
As Annabel was a rather, ah, big girl, the sonogram was technically difficult to perform. However, when I put the probe over her spleen I saw what appeared to be fluid between it and her left kidney.
I moved the probe over to her right side and placed it over her liver, and this time there was no doubt: fluid. Blood. A lot of blood.
The next several minutes were spent drawing labs and getting X-rays. Other than a fractured left humerus, nothing jumped off the screen at me. Even her initial lab work was normal, except for one number: her blood alcohol level was over three times the legal limit.
Sigh. God damn it, Annabel.
The questions in my mind immediately became 1) Where was that blood coming from, 2) Was it still bleeding, and 3) What do I have to do about it? Based on the mechanism of injury, the most likely culprits were the liver and/or the spleen (obviously), but there are several other potential sources (mesentery, omentum, bowel, diaphragm, pelvis, major vessels, etc).
Once I was sure her blood pressure was stable, we brought her over to the CT scanner. The pictures flashed through very quickly, but even a blind parking meter maid would have been able to see the large laceration on the right lobe of her liver. Her brain was fine, and her other scans showed no other injuries.
Fortunately the vast majority of liver lacerations stop bleeding spontaneously and require no intervention whatsoever. Over the next 36 hours, Annabel's bleeding stopped, and her boyfriend and father showed up to claim her. And this is where we pick up our story.
"So the first lesson to be learned here," Annabel's boyfriend started as he tapped her foot with a relieved smile, "is wear your seat belt. And the second is not to crash!", he laughed. I didn't.